Sunday, June 28, 2009

RE: Single Payer is Not Necessarily the Best or Only Option

Dear Health Care Advocates:

I just listened to the YouTube video of Dr. Anne Scheetz of Progressive Democrats of America, entitled, "Single Payer and the Public Option," advocating for Single Payer. I listened to it as an example of the arguments for Single Payer vs. Public Option. I listed to this YouTube video as an example of the arguments for Single Payer.

I find a few of serious problems with Dr. Anne Scheetz's contentions, based on my experience with the health care systems in France, Great Britain, Brazil (and even Sandinista Nicaragua):

1). She says,

There is no country that has anything like universal coverage that has for-profit insurance companies. There is no such thing.

This is simply not true. I lived in France for thirty months as a foreign student who was covered 100% by the national health system because my medical problem was recognized as particularly severe. Others with less serious medical problems had co-pays, but no one that I know complained about those co-pays. However, the co-pays were based on income and those with lower incomes had lower co-pays. In fact, many people bought private insurance for the purpose of covering the co-pays.

When I was in France, the medicines I needed were 100% paid for by the French government. For this coverage, and including my yearly tuition at the university, I paid a total of about nine hundred dollars per year. My yearly insurance premium, based on my income, was about $3 to $400 dollars. Again, I never heard any complaints from French people about their Government medical system, which wealthier people supplemented with private plans.

One of my ex-girlfriends, who is unemployed, virtually penniless and not a French citizen, just had a baby in France and she had not a single complaint about the medical care she received under the French government's national health care system.

France does not have completely nationalized medical care; the Government pays private practitioners to provide much medical care according to set rates.

Some of the most important features of the French system are not strictly financial but have a great impact on the cost and feasibility of providing excellent medical care. In France, all health billing is done by computer and doctors can see a patient's complete medical records on their desktop computers. Charging the government for a medical service less complicated than buying a book at The savings from taking the bureaucracy and wasted person-hours out of the system are spent on medical care instead.

Based on my experience during thirty months in France, and all that each of us has read, I think everyone acknowledges that French people are as happy with their Government-provided insurance as most anyone in the world. In France, Government-provided insurance exists alongside for-profit insurers, but it is entirely possible there to get one's medical needs taken care of, even as a foreign student, without buying private insurance.

2). Dr. Anne Scheetz summarizes her argument by saying,

"We say, we can only have universal coverage for everyone if we eliminate the private insurance industry."

I do not believe that is true (particularly based on my experiences in France and England).
Moreover, I know that this is not true based on my present experience in Brazil, whose Government offers a comprehensive Unitary System for Health (SUS) as well as a comprehensive mental health system (CAPS), including an array of free psychiatric and psychosocial alternatives and free medications, and this system exists alongside private insurers which are not much better than those in the United States.

The Brazilian system's quality depends on the commitment of local prefectures, but provides care everywhere in Brazil. Wealthier people who want better or faster care self-insure or buy private health coverage.

Politically, I do not believe Single Payer is feasible right now in the United States, even if we elect a socialist president and Congress. Does anyone actually believe that the present US Congress is going to vote to eliminate the private insurance industry over the next few weeks? If anyone in Congress had any intention of doing that, wouldn't we have heard about it by now?

I am a socialist and have no ideological problem with eliminating the private insurers. But elminating the entire private insurance industry simply is not going to come out of this Congress. And so (between you and me), this simply has no chance of happening and we have to demand what we want while accepting the best we can get under the circumstances.

As a matter of strategy, demanding the elimination of insurance companies may be an effective way of getting a more comprehensive government plan that provides a better alternative to the insurance companies. So, advocating for single payer is good in that respect. But ideological rigidity is not good and the best may be the enemy of the better in this case.

3). I also spent a two weeks stay in England, hosted by a middle-aged professional couple who had various medical issues. What I observed personally in England and to a much lesser degree in France that the Government plans do not cover any meaningful dental maintenance and so, particularly in England where dentist are harder to find and costs are higher, the condition of even upper middle class people's teeth is often abominable. I met an English physician whose teeth appeared never to have been taken care of at all.

While I was in England my hosts explained to me that the costs and waits for canal work and crowns were nearly overwhelming. It is very difficult and expensive to get dental care in England and equally expensive but otherwise not as difficult in France. Any Government plan must cover comprehensive dental care or it fails to cover the person's whole body.

In comparison, Brazil has many excellent dental schools that turn out a steady stream of excellent dentists. The fact that they are plentiful keeps down the cost and increases the temporal availability of dental care, and so many Brazilians have teeth in much better condition than people in France and Great Britain. The key is to produce more dentists who compete with each other. In any case, be it Government option of private practice, it will not be possible to take care of the nation's teeth unless the nation has more dentists and correspondingly lower wait times, particularly in England and the United States.

Finally, the difficulty with convincing Americans that Single Payer is the only good option is simply that Single Payer is NOT the only effective option and Single Payer would require the nationalization or purchase of all of the insurance companies, whose stock holders will not be happy or pliable unless their return on investment from nationalization is higher than it would be while continuing what they are doing now. Even while virtually nationalizing GM, the Government has not proposed to make cars and cut private investors entirely out of the loop.

Let's be realistic, and intransigent perhaps as a political strategy, but realistic as a political necessity.


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